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General NPI Number Information
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NPI Number | 1457377848
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Entity Type | Organization
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Legal Business Name | OVERLAND OPTICAL, INC.
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Dates
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Enumeration Date | 07/15/2006
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Last Update Date | 01/13/2011
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Provider Practice Location Address
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Address Line | 2533 WOODSON RD
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City | SAINT LOUIS
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State | MO
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Zip | 63114-5436
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Country | US
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Telephone | 314-423-3874
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Fax | 888-423-0074
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Provider Business Mailing Address
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Address Line | 2533 WOODSON RD
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City | SAINT LOUIS
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State | MO
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Zip | 63114-5436
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Country | US
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Telephone | 314-423-3874
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Fax | 888-423-0074
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Authorized Official
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Title or Position | OWNER/PRESIDENT - OPTICIAN
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Name | MR. RUSSELL GENE DENTSBIER
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Credential | ABOC
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Telephone | 314-423-3874
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 036582
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License Number State | MO
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